CHRISTCHURCH CITY BMX CLUB INC.

PO Box 16058, Hornby

Christchurch 8441

http://www.christchurchcitybmxclub.com

chcbmx@hotmail.com

MEMBERSHIP APPLICATION FORM 08/09

Valid 1 August 08 to 31 July 09

RIDER/S NAME/S _______________________________________________

PARENT/CAREGIVERS NAME/S _______________________________________________

ADDRESS _________________________________________________________________

PHONE NUMBER ___________________ MOBILE NUMBER_______________________

FAX NUMBER ___________________ DATE of BIRTH _________________________

EMAIL ______________________________________________________________

EMERGENCY CONTACT DETAILS______________________________________________

MEDICAL CONDITIONS IF ANY _______________________________________________

BMX NZ LICENCE NUMBER (if transferring from another club) _______________________

PAYMENT

TYPE OF MEMBERSHIP INDIVIDUAL $25 _________

FAMILY $35 _________

UNIFORM REQUIRED $20 NON REFUNDABLE _________

Subject to availability

BMX NZ LICENCE REQUIRED see additional BMX NZ form _________

TOTAL PAID $_________

I/We agree that:

BMX is a contact sport and we will not hold the club responsible for personal injury or damage to property.

I/We will not bring the Christchurch City BMX Club into disrepute.

I/We agree to abide by the rules of the constitution of the Christchurch City BMX Club and BMX NZ (These are available online).

The Christchurch City BMX Club reserves the right of applicants to the club.

Signed…………………………………………….. Date……………………….

If under 16 years of age parent or guardian signature required

_____________________________________________________________________________

CHCH OFFICIAL RECEIPT NUMBER ISSUED

BMX NZ FORM / BIRTH CERTIFICATE

CLUB NUMBER GIVEN